Strange but true, a DNR tattoo

Last summer, when physicians at Jackson Memorial Hospital in Miami cared for an unidentified,
unconscious 70-year-old man, they were unaware that an urban legend was about to be
proven true.

Dr. Holt

At first, the man's alcohol level was elevated, his blood glucose was fine, and clinicians
presumed he'd sleep it off in the ED. But as morning came, the man wasn't waking up,
and Gregory E. Holt, MD, PhD, was called down from the ICU to evaluate him. The man
had tachycardia and hypotension, and when Dr. Holt ordered an arterial blood gas test,
the pH result was 6.81.

“It was an acute respiratory acidosis, so clearly the man is not ventilating
well and we need to do something,” said Dr. Holt, a pulmonary and critical
care physician. “That's about the same time when we noticed this ‘Do
not resuscitate’ (DNR) tattoo...right where you'd have to put your hands to
do chest compressions.”

Dr. Holt, an assistant professor at the University of Miami Health System, recounted the confounding case in a letter published on Nov. 30, 2017, in The New England Journal of Medicine. He recently spoke with ACP Hospitalist about the experience.

Q: What was your first reaction when you saw the DNR tattoo?

A: You think of these things as urban legends, or at the end of a code, someone will
say, “I'm going to have ‘DNR’ tattooed on my chest so this never
happens to me.” So we finally see one . . . and you don't really know what
to do. We don't know is this a real tattoo, is this not his real wishes, and is it
even legal? We want to think only about the patient's health, but to do so, you have
to say, “Is this tattoo a realistic manifestation of his true wishes for life-sustaining
therapy?”

Q: What were your next steps?

A: Initially, we make the decision to do some temporizing measures. We put him on bilevel
positive airway pressure because I felt like without it, he would cease breathing.
We give him fluids, antibiotics, and we put him on vasopressors because without it,
we figured he would go into cardiac arrest from PEA [pulseless electrical activity].
By doing these things, I felt like we could temporize everything while we tried to
figure out the legality, the veracity, and who he was. Everything we did—we
gave him sugar and oxygen, tried to wake him up—to get him more conscious failed.
After treating the patient and thinking about it, that's when it dawned on us that
we really needed ethics [to consult]. It was within the first two hours of us seeing
the man that ethics got involved.

Q: What did the ethics consultant determine?

A: Ken Goodman, PhD, is our ethicist. He is amazing. He did a great job, I thought—really
looked at the case, looked at the patient, looked at the tattoo. The thing about this
man's tattoo is he spelled out the words, he underlined the word “not,”
and he even put what we presumed was his signature, but there was no way to actually
determine that exactly. So [he] thought, given all the things that the patient did
to get that tattoo, most likely this was consistent with his wishes. It probably took
him one to two hours after getting called for him to think it through, and then we
said, “All right, we'll make him DNR then.” We provided for comfort,
of course, and he ultimately passed away, probably about a full 24 hours from when
he presented to the emergency room.

Later that night, the social worker was finally able to identify the man. They called
his place of residence to try to get some more records. When they went into his domicile,
they found his Physician Order for Life-Sustaining Therapy form, and it was consistent
with his tattoo. That just made us all feel very reassured that ethics was spot-on
brilliant in their evaluation and analysis of this patient's case.

Q: What kinds of reactions have you gotten to how you handled this case?

A: Some people suggest that the DNR tattoo should not have been honored. What Florida
[law] suggests is you need to have it on yellow paper. If it's not on yellow paper,
you are not legally mandated to honor it. A lot of people, actually, say the opposite:
that we shouldn't have even had a discussion—we should've looked at the DNR
tattoo and said, “This is a manifestation of the man's wishes; honor it.”
A couple of people have called me cold and distant and too professional without caring
for patients because of what I did.

In his case, [the tattoo] prevented him from being intubated. So on a case of n=1, it clearly worked. Was it easy? No. Did it cause us a lot of confusion? Absolutely.
There's one other case, I think it was in 2012, of a man with “DNR”
on his chest, and it turned out he just lost a bet while drunk. When he was asked,
he said two things: First, no, he did not want to be DNR, and two, he didn't think
anybody would take it seriously that he actually had a DNR tattoo. I think that kind
of gets to the root of DNR tattoos in terms of conveying somebody's wishes for life-sustaining
therapy: Although it sounds like a good idea, it doesn't always translate into an
appropriate response from providers who actually see the patient.

Q: What advice would you give hospitalists based on this experience?

A: Know that you have an ethics department and just be able to use them. That's the biggest
thing that I've taken from this. Even if they had come down and made that decision
that we should honor [the tattoo] and then later we find out that it wasn't [the man's
wish], I would still feel better that we had somebody who's an expert in ethics come
to a conclusion that was based on the facts and the evidence of a case to the best
of our ability. I hope, after all these discussions that have come out of this, that
it starts a national conversation about a better system to get in place to get people's
end-of-life wishes known.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.